Report Date


Case Against

Betsi Cadwaladr University Health Board


Clinical treatment outside hospital; Physiotherapist

Case Reference Number



Upheld in whole or in part

Ms R complained that the Health Board failed to take appropriate action to minimise the risk of her mother, Mrs A, falling while she was mobilising to the toilet in hospital on 27 February 2019 and that it did not conduct an appropriate investigation into the circumstances surrounding Mrs A’s fall. Ms R also complained that the Health Board failed to ensure that a physiotherapy assessment and care plan, agreed on 22 July for Mrs A, was appropriate. She also complained that the frequency and regularity of her mother’s community-based physiotherapy was inadequate to meet Mrs A’s needs and that clear and meaningful communication was not provided between 22 July and 12 November.

The Ombudsman found that, whilst it was difficult to determine with any certainty the exact sequence of events relating to Mrs A’s fall, it did not appear that the Health Board had taken all appropriate actions to secure Mrs A’s safety when mobilising to the toilet. There was insufficient evidence to demonstrate that the Nurse was aware Mrs A required 2 people to help her mobilise, or to support the Health Board’s suggestion that the Nurse was awaiting a second staff member when Mrs A began walking independently, leading to her fall. Furthermore, he found that discrepancies and inconsistencies throughout the records and the Health Board’s investigation meant that the Health Board’s findings about what happened were irreconcilable with the available evidence. He upheld both of these complaints.

The Ombudsman found that, despite some dispute regarding the precise details of the assessment and care plan decided on 22 July, the documented care plan was clinically relevant and appropriate to meet Mrs A’s needs.

He also found that, whilst the number of physiotherapy sessions provided between 22 July and 12 November was less than had been documented or agreed, there was no clinical detriment to Mrs A and her progress was comparable to her ability when she had been receiving physiotherapy more frequently. The Ombudsman did not uphold these complaints. However, he partially upheld Ms R’s complaint about communication. Whilst the evidence supported that Mrs A and Ms R were appropriately engaged with her care plan and involved in relevant decisions, he found there were failures to explicitly clarify the care plan and to explain the reasons why the number of sessions provided were fewer than what Mrs A, and Ms R had been expecting.

The Ombudsman recommended that, within 1 month, the Health Board should apologise to Mrs A and Mrs R for the failures identified, and offer Mrs A £250 in recognition of the failures in the Health Board’s investigation into her fall. He also recommended that the Health Board should reconsider the failures relating to Mrs A’s fall, and the repercussions for her, under a process akin to the NHS complaints process “Putting Things Right”, and complete its reconsideration in line with the timescales applicable from that process. He also recommended that relevant staff should be reminded of the importance of clear communication, detailed record keeping, and comprehensive investigations when incidents occur. Finally, the Ombudsman recommended that, within 3 months, the Health Board should review its policy for Physiotherapy staff providing care in the community to clarify what they should do in the event that they are unable to attend a property to provide community-based care.